_{Please complete this form and return it back with the required documentation and information.}

_{Please note  that we will not be able to process your claim without the documents and information requested on this form.}

_{A claim against M&F Risk Financing, the broker we represent and their insured can take up to 8 weeks to}

_{finalise, and we need to inform you that the follow-up lies with you.}

_{Please note that M&F Risk Financing is not party to the Knock-for-knock agreement as of 01.06.2013.}

_{The documents must be forwarded to: Belinda Bardenhorst belinda@stratsys.co.za}

_{CLIENT DETAILS:}

_{Claim number: ________________________ Client: ____________________________________}

_{THIRD PARTY DETAILS:}

_{Home tel.: ____________________________ Work tel.: _________________________________}

_{Cell no.: ______________________________ E-mail: ____________________________________}

_{Vehicle information for appointing an assessor:}

_{Registration number of vehicle: ___________________________________________________}

_{Make of your vehicle: ______________________________________________________________}

_{The year model: __________________________________________________________________}

_{Where is your vehicle currently: _____________________________________________________}

_{Is your vehicle driveable [YES/NO] ___________________________________________________}

_{Was your vehicle towed from the accident scene [YES/NO] _______________________________}

_{If “YES” please advise us where your vehicle was towed to. E.g. Panel beater/ Towing Company or Residential}

_{place ___________________________________________________________________________}

_{If towed to a Towing Company kindly provide us with a copy of the towing invoice.}

_{Please note that if your vehicle is standing at a Towing Company/Panel Beater’s premises we will not be  responsible for the storage, security and admin fees.}

_{We do not pay car hire costs, unless the vehicle is used for business purposes to generate income and proof will be required.}

_{Required Documentation from the Third Party is as follows:}

_Vehicle:

• _{Vehicle Registration Certificate (NOT the Vehicle License Certificate); please note the reason why we require a copy of your vehicle registration is to prove ownership in the event that you are claiming for damages on a vehicle.}
• _{Copy of ID of the registered owner;}
• _{SAP number or police report}
• _{Copy of the driver’s license [the person driving at the time of the collision]}
• _{Sketch and description of how the accident happened (to be done by the driver at the time of the accident);}
• _{If you do not have insurance please provide a letter (known as a no claim letter) from you insurer confirming that you will not be claiming from them for the accident; OR if you do not have insurance provide an affidavit of non-insurance done by the registered owner of the vehicle.}
• _{Supply 2 quotations for the damage of the vehicle.}

_OPTIONAL:

_{If you do have an independent witness, not a passenger in your vehicle, please advise your witness to}

_{complete the witness form below:}

_{WITNESS STATEMENT FORM:}

_{Full names: _______________________________________________________________________}

_{Home Address: ____________________________________________________________________}

_{Work Tel.: ________________________________ Cell no.: _________________________________}

_{E-mail address: _____________________________________________________________________}

_{When, where and how did the accident happen:}

_{Date of accident: ________________________________ Time: _____________________________}

_{Weather conditions: ______________________________ Visibility: _________________________}

_{Street/Intersection: _________________________________________________________________}

_{Suburb/Town: _____________________________________________________________________}

_{Vehicles involved: __________________________________________________________________}

 _{Where were you at the time of the accident: _____________________________________________}

_{Accident Description:}

_{Please give us the detailed description of how the accident happened:}

_{__________________________________________________________________________________}

_{__________________________________________________________________________________}

_{__________________________________________________________________________________}

_{Accident Sketch:}

_{Please draw a sketch showing the accident and indicate where you were at the time of the accident:}

_{SIGNITURE: _________________________________ Date: ________________________________________}